Selected practices among rural residents versus the prevalence of ...

Selected practices among rural residents versus the prevalence of Amoebiasis and Giardiasis in NjoroDistrct, Kenya.Kinuthia G.K 1 , Afolayan F.I.D 2 , Ngure V 3 , Anjili C.O 4 ,1 Daystar University, School of Science, Engineering & Health, PO BOX 44400, Postcode: 00100, Nairobi, Kenya.2 University of Ibadan, Cellular Parasitology Programme, Department of Zoology, POBOX 8761, Ibadan, Nigeria.3 Chepkoilel University College, Department of Biological Sciences, PO BOX 1125, Post code30100, Eldoret, Kenya.4 Center for Biotechnology Research and Development (CBRD), Kenya Medical ResearchInstitute (KEMRI).Corresponding author: Geoffrey K. Kinuthia, Lecturer in the School of Science, Engineering and Health, DaystarUniversity, PO BOX 44400 Nairobi, Post Code 00100, Kenya Mobile Phone Number: +254-734705480; E-mail:gkinuthia2002@yahoo.com or gkinuthia@daystar.ac.keSUMMARYThe study was designed to investigate on selected practices among rural population, and their likelycontribution to the spread of amoebiasis (E. histolytica) and giardiasis (G. lamblia). A cross sectional studywas carried out in three villages, namely Kikapu, Piave and Belbar in Njoro District, Kenya. Questionnaire,interviews and personal observations were used to obtain data from 336 randomly selected consentingindividuals in homesteads in the three villages. A retrospective study was further carried out to establish theprevalence of E. histolytica and G. lamblia among outpatients attending two randomly selected health centersin the study area. Majority of the respondents’ highest education level was basic primary school education(61%), unemployment (98%) and with a monthly expenditure of less than 2200 Kenya Shillings or 28 USDollars (81%). Eighty percent of the respondents were classified under low economic status. Eighty twopercent reported lack of piped water and boiling of drinking water was less likely to occur among the loweconomic status respondents (Odds ratio (OR) = 0.423, 2 = 9.88; 95% CI of -5.74 to 6.58). However,washing of hands with soap after using a latrine seemingly was not influenced by economic status of therespondents (OR = 1; 2 = 0; 95% CI = 0). The level of education seemed to influence on the adoption ofrisky practices, such as, failure to boil drinking water was more likely to occur among respondents who hada low academic level (OR = 0.84, 2 = 0.04, 95% CI of -2.27 to 3.95). The stool tests records at Njoro PCEAhealth center showed that the prevalence of E. histolytica (20.83%) and G. lamblia (20.32%) were higherthan the corresponding prevalence at Njoro County Council health center which were 1.34% and 0.00%respectively. Concurrent infections of E. histolytica and G. lamblia were absent in the two health centers. Thetrend of E. histolytica and G. lamblia followed an alternating pattern, in which an increase in one directlycorresponded to a decrease in the other and vice versa in the two health centers. It was concluded thatpoverty and low education levels were significant factors that influenced on the adoption of risky lifestylesthat were likely to enhance parasitic infections. There is a need for reliable diagnostic methods other thandirect microscopy for E. histolytica and G. lamblia stool tests in order to minimize the wide variation of theresults in the two health centers. Public health education should also be enhanced to discourage the adoptionof risky practices.[Afr J Health Sci. 2012; 20:11-20]African Journal of Health Sciences, Volume 20, Number 1-2 January-March 2012

IntroductionAccording to WHO [1], health is a state of completephysical, mental and social well being. The ‘Alma-Ata Declaration’ postulated that an acceptable levelof health for all people in the world should have beenachieved by year 2000 [2]. Many developingcountries may not have achieved this target. InKenya, provision of health has been influenced byfactors like the level of education, socialstratification among others. People with higher levelsof educations tend to be healthier than those ofsimilar income who are less well educated and thatthose in ‘upper’ social strata tend to show lowmortality rate and less morbidity rate due toinfections because they seek medical attention early[3]. In addition, rural populations in developingcountries tend to face problems of unhygienicpractices, which may contribute to the transmissionof parasitic diseases [4]. Infectious parasitic diseasesremain the primary cause of morbidity and mortalityin tropical countries where, being in contact withmicroorganisms and transmission of microorganismsis higher [5]. The prevalence of intestinal parasiteinfection is influenced by factors like poor sanitationand hygiene, age of the individuals, the type ofparasites, the climate and the presence of animalsknown to be involved in the transmission of theparasites [6].Amoebiasis and giardiasis are intestinal protozoainfectious diseases usually contracted by ingestingfood or water contaminated with cysts. Autoinfection also plays a key role in the transmission ofgiardiasis [7]. The causative agents for amoebiasisand giadiasis are E. histolytica and G. lambliarespectively. The E. histolytica, whose occurrence ishighest in the tropics, is thought to be carried in theintestine of one-tenth of the world’s population and itkills around 100,000 people per year [8]. Amoebiasisexists in intestinal and extra-intestinal formscharacterized by dysentery, abdominal pain, fever,diarrhoea, weight loss, amebic hepatitis andpulmonary amoebiasis [8]. On the other hand, G.lamblia, has an incidence of between 100,000 to 1million cases per year [8]. Giardiasis leads tosymptoms ranging from mild diarrhoea, flatulence,vague abdominal pain, acute and/or severe diarrhoeato steatorrhea and a typical mal-absorption syndrome[9]. Diarrhoea is a condition which increases thestool weight in excess of 200g per 24 hours withincreased water content leading to lose of water andelectrolytes from the body [10]. Some of the clinicalfeatures associated with amoebiasis includehyponatremia and hypokalemia [11]. A drop inelectrolytes can lead to a drop in the blood volumewhich may affect the blood pressure among otherconditions. Concurrent giardiasis and amoebiasisinfections have been associated with delayedrecovery from childhood malaria especially in thetropics [12]. The current research was aimed atestablishing the prevalence of amoebiasis andgiardiasis among patients residing in rural areas andthe predisposing practices that have been adopted bythese rural residents.Materials and methodsStudy area:The study was carried out in Njoro District, Kenya.Njoro is 20 km southwest of Nakuru town, in the RiftValley Province. The residents of Njoro are mainlysubsistence farmers, small traders and civil servants.The data was collected from three villages, namelyKikapu, Piave and Belbar and from two randomlyselected health centers where the residents of thesevillages sort treatment. These health facilitiesincluded Njoro PCEA and Njoro County Councilhealth centers.Study design:A cross-sectional study that involved observationalapproach and use of questionnaires to determine thefrequency of socio-economic, socio-demographicand parasitic disease control practices was carriedout. The target group comprised of 336 respondentsin randomly selected homesteads from the studyarea. Preference was given to the owners of thehomesteads visited. A retrospective study in whichhealth records were retrieved from two randomlyselected health centers in the study area was alsodone. The frequencies or prevalence of amoebiasisand giardiasis among patients seeking treatment atNjoro PCEA (private) and Njoro County Council(government) health centers which are located in thestudy area were investigated. The laboratorydiagnostic method used in the two health centers forboth the amoebiasis and giardiasis involvedobservation of iodine stained fresh stool samplesusing a light microscope.Ethical issues:Permission to carry out the study was obtained fromthe Department of Research, Publication andConsultancy at Daystar University. The Chief, the11

District officer, and the area Member of Parliamentin the study area were consulted and their writtenapproval was granted. In addition, the local churchesand schools were informed about the research andtheir readiness to cooperate was granted. Writtenpermit to enable us retrieve data from the healthcenters was provided by the District medical officers.Data collected, data analysis and presentation:Socio-demographic and socio-economic variablesthat included, the age, sex, marital status, family size,education level, occupation, and indicators ofeconomic status of the respondents were recorded.In addition, aspects of lifestyle or daily practices thatmay have enhanced the transmission of amoebiasisand giardiasis were recorded. Prevalence ofamoebiasis and giardiasis among the patientsresiding in the study area (villages) and seekingtreatment from the selected heath centers from 2004to 2009 were noted in a standard form. Statisticalanalysis included computing percentages, means,odd ratios and chi square tests. The chi square testwas used to establish relationship between variablesin a 2 × 2 contingency table.ResultsSocio - demographic and socio - economic variables:Table 1: Showing the educational level, occupation and of the economic status of the respondents (n = 336)._____________________________________________________________________________Variable Category Respondents Percent (%)_____________________________________________________________________________Respondent’s gender: Male 128 38.10Female 208 61.90Education Level: None 62 18.45Primary school 199 59.23Secondary school 67 19.94College 6 1.79University 2 0.60Employment/Occupation: Unemployed 328 97.62Employed 8 2.38Small scale farmer 323 96.13Large scale farmer 1 0.30Small scale traders 12 3.57Average monthly Less than 1000 158 47.02spending in Kshs a : 1000 to 2200 114 33.932201 to 3401 30 8.933402 to 4602 6 1.794603 to 5803 1 0.305805 to 7004 4 1.19More than 7005 1 0.30Opted not to disclose 22 6.55Economic status b : Low 268 79.8Medium 67 19.9High 1 0.3______________________________________________________________________________aThe average income per month = Total money spent per month divided by the number of individuals using the moneyin that homestead every month [Exchange Rate: 1 US Dollar = 80 Kenya Shillings (Kshs)].bA respondent must have scored 78% (7/9 variables) to qualify for being in a specific category. Note: the type of thehouse; car or tractor ownership, size & ownership of the land and average income per month, were the compulsoryaspects that were included in the 7 variables used to compute the 78 %. [13]12

Selected lifestyles and practices:Table 2: Showing some selected practices adopted by the respondents (n = 336).______________________________________________________________________________Variable Category Respondents Percent______________________________________________________________________________Water source: Piped water present in the homestead 59 17.56Piped water absent in the homestead 277 82.44Protected rain water tank present 150 44.64Non-protected rain water tank present 45 13.39Rain water tank absent 141 41.96Centralized community watering point 277 82.44Domestic dams 76 22.62Rivers 26 7.73Drinking water: Boil drinking water always 130 38.69Do not boil drinking water always 206 61.30Pit Latrine a : Clean pit latrines 269 80.06Dirty pit latrines 58 17.36Latrines absent 9 2.68Washing hands Do not wash hands 26 7.74after using a Do not always wash hands 28 8.33latrine: Always wash hands in a basin 266 79.16Always wash hands in running tap water 16 4.76Washing hands Use soap 291 86.60with soap after Do not use soap 45 13.39using a latrine:Toiletries: Use toilet papers always 227 67.55Do not use toilet paper always 109 32.44_________________________________________________________________________________________aFeatures of a clean latrine were: washed with clean water; a dry clean floor; no flies; no cobwebs; and no evidence offeacal materials or urine on the floor.African Journal of Health Sciences, Volume 20, Number 1-2 January-March 2012

Statistical comparison of selected practices versus economic levels of the respondents:Table 3: Shows a 2 × 2 contingency table used to compute Odds Ratio (OR) for the aspect of boiling drinkingwater among the low and medium economic cadres; n = 335.____________________________________________________________________________Respondents whoRespondents who doboil drinkingnot boil drinkingEconomic status water water Total____________________________________________________________________________Low 92 176 268Medium 37 30 67Total 129 206 335 aOdds ratio (OR) computation = 9230/17637 = 0.423, (therefore, OR< 1)____________________________________________________________________________aThe total number of respondents was 335 because 1 respondent was classified as high economic status (Table 1).Table 4: Summary of the ORs for the selected practices calculated using 2×2contingency tables, for the low economic cadre; n = 335.Boil Use soap to AlwaysEconomic Total drinking wash hands use a toiletstatus number water after latrine paperLow: 268 92(34 %) 232(87 %) 171(64 %)Medium: 67 37(55 %) 58(87 %) 55(82 %)OR: 0.42 1 0.38Chi Square ( 2 ): 9.88 0 8.1695% Confidence Interval (CI): -5.74 to 6.58 0 -5.22 to 5.98Tables 3 and 4 show that boiling drinking water andalways using toilet papers were practices that werenon-significantly less likely to occur in the loweconomic group of respondents. The statisticalevidence to support this was that, Odds Ratio (OR) 1, and 95% confidence interval(CI) was inclusive of 1. Washing hands with a soapafter using a pit latrine had an equal probability ofoccurring in both the low and medium economiccadres of the respondents (ORs = 1, 2 = 0, and 95%CI = 0).Statistical comparison of selected practices versus education levels of the respondents:Table 5: Showing the computed ORs for the selected practices when different educationlevels of the respondents were compared; n = 336.BoilUse aAcademic Total drinking soap to washlevel number water hands after latrine Primary level: 261 94(36 %) 214(82 %) Secondary level: 75 30(40 %) 68(90 %)OR: 0.84 0.47Chi Square ( 2 ): 0.40 3.2595% Confidence Interval (CI): - 2.27 to 3.95 0.62 to1.5614

Table 5 shows that the aspect of boiling water wasnon-significantly less likely to occur amongrespondents who had an academic level of primaryschool and below (OR = 0.84, 2 = 0.04, 95% CI of -2.27 to 3.95). Similarly, use of soap to wash thehands after using a latrine was also non-significantlyless likely to occur among those with lowereducation level (OR = 0.47, 2 = 3.25, 95% CI of0.62 to 1.56).Retrospective studies: Prevalence of E. histolyticaand G. lamblia based on laboratorystool tests, in the selected health centers:Out of 3059 stool tests from the study area carriedout between 2004 and 2009 at Njoro County CouncilHealth Center, 1.34% of the tests were positive for E.histolytica; 0.00% for G. lamblia and 0.75% forintestinal worms (Table 6). Similarly out of a total of984 stool tests carried out between 2004 and 2009 atNjoro PCEA health center, 21% were positive for E.histolytica; 20% for G. lamblia and 5% for intestinalworms (Table 7). The total stool tests at Njoro PCEAhealth center indicated that the prevalence of E.histolytica and G. lamblia tended to be equal in adultmales and adult females with a ratio of 1:1 (Table 7).The stool tests at Njoro County Council Healthcenter gave a ratio of 7: 2: 1 adult females, adultmales and children respectively (Table 6), implyingthat more adult females were referred for the stooltests.Table 6: Stool tests results for gut parasites at Njoro County Council Health Centerfrom 2004 to 2009.Stool TestsYear Total tests (F/M/C) a E. histolytica G. lamblia Intestinal worms2004 316 (245/40/31) 6 0 02005 496 (373/85/38) 6 0 62006 466 (339/101/26) 8 0 32007 581 (376/144/61) 8 0 22008 605 (430/115/60) 1 0 122009 595 (389/110/96) 12 0 0Total 3059 (2152/595/312) 41 0 23Average/year 510 (359/99/52) 7 0 4Ratio 7: 2: 1Prevalence (%) 1.34 0.00 0.75(F/M/C) a = adult females/adult males/childrenAfrican Journal of Health Sciences, Volume 20, Number 1-2 January-March 2012

Table 7: Shows the positive stool tests for gut parasites at Njoro PCEA health centerfor the years 2004 to 2009.Positive (+ve) TestsTotal E. histolytica G. lamblia Intestinal wormsYear patients (F/M) b (F/M) (F/M)2004 168 31(14/17) 29(14/15) 2(2/0)2005 148 33(14/19) 32(21/11) 7(5/2)2006 228 50(25/25) 32(18/14) 9(8/1)2007 c 142 33(13/20) 35(17/18) 14(4/10)2008 c 118 28(12/16) 22(11/11) 9(4/5)2009 180 30(14/16) 50(27/23) 4(2/2)Total 984 205(92/113) 200(108/92) 45(25/20)Average/year 164 34(15/18) 33(18/15) 7(4/3)Ratio 1:1 1:1 1:1Prevalence (%) 20.83 20.32 4.57(F/M) b = Adult females/adult males; c Data for December 2007 and April 2008 was not available.It was further noted that all the positive tests at NjoroCounty health center were significantly lower thanthose of Njoro PCEA despite the former having alarger number of patients.Concurrent infections of E. histolytica and G.lamblia:The stool samples that were positive for both E.histolytica and G. lamblia (concurrent infections)were conspicuously absent in the two health centersstudied. Out of 984 stool tests carried out, from 2004to 2009, there were 0 amoebiasis/giardiasis coinfectionsrecorded at Njoro PCEA health center.Similarly, out of 3059 stool tests, there were 0amoebiasis/giardiasis co-infections cases recorded atNjoro County Council Health Center in the sameperiod.The yearly trend of E. histolytica and G. lambliacases at Njoro PCEA health center:Figures 1 and 2 shows that the cases of amoebiasisand giardiasis at Njoro PCEA health center had atypical alternating pattern in which an increase inamoebiasis at a particular time tended to correspondto a decrease in giardiasis at the same time and viceversa.Fig 1: Trend of amoebiasis and giardiasis casesat Njoro PCEA Health Center in the year 2006.16

prevalence include; not boiling drinking water(61%); using water that was likely to becontaminated for instance, rivers (8%), public damsand domestic dams that trapped surface runoffs afterthe rains (23%) and communal water collectingpoints (82%); inadequate and inappropriate washingof hands after using the latrines (16%), washing ofhands in a basin of water (79%) instead of runningtap water; dirty latrines with flies and being locatednear the houses (17%) and in some cases absence oflatrines (3%); inadequate and inappropriate use oftoiletries in the latrines hence increasing the chanceof fecal contamination (36%); and failure to use soapwhen washing hands after utilizing a latrine (13%).Fig 2: Trend of amoebiasis and giardiasis casesat Njoro PCEA Health Center in the year 2007[data for the month of December was missing inthe records availed].DiscussionThe combination of illiteracy and increasedunemployment (Table 1) must have contributed to arelatively higher rate of poverty in the study area.The current research established that 80% of thoseinterviewed were spending less than a dollar per dayand therefore a large number of those interviewedmust be spending little for their health care (Table 1).This observation is in line with Stanhope andLancaster [14], who concludes that poverty affectsdirectly the persons’ health wellbeing and that poorpersons tend to be associated with more complexhealth problems. Some of the health risks associatedwith poverty includes unemployment, poor academicachievement, and unaffordable or inaccessible healthcare [15].Adoption of practices that may predispose anindividual to infectious agents can promote thespread of parasitic infections among humans. Thisresearch identified such practices to be commonamong the rural residents in the study area and theycorresponded to increased prevalence of someparasitic diseases in the local health center where theresidents sought their treatment. Table 2 shows thevarious practices among the residents in the studyarea which might be contributing to the spread ofamoebiasis and giardiasis. These practices and theirThe failure to boil drinking water seemed to beinfluenced by factors like economic status and thelevel of education. Boiling of drinking water was lesslikely to occur among the low economic statusrespondents (Odds ratio (OR) = 0.423, 2 = 9.88;95% CI of -5.74 to 6.58) (Table 3). Probably this wasdue to lack of enough money to buy the fuels.Similarly, the aspect of boiling water was less likelyto occur among respondents who had an academiclevel of primary school or below (OR = 0.84, 2 =0.04, 95% CI of -2.27 to 3.95). This thereforeimplies that health education in rural areas isnecessary in order to enhance the adoption ofhygienic practices and appropriate lifestyles. A studycarried out in the villages of Panipat of HaryanaState, India on a sample of 60 rural school goingchildren aged 8 -10 years concluded that if a needbased school health education program is developedfor different age groups, it leads to improvement andpractices regarding personal hygiene [16].These unhygienic practices among the residents inthe study area can lead to feacal contamination of thehands and predisposing the residents to infections.According to Radford [17] more than half of thepeople in the world carry around inside them an‘intestinal zoo’ of parasites, majority of which aretransmitted to human by swallowing the egg or thecyst forms of the parasite in contaminated food,water or through contamination of the hands byinfected feaces or feacally contaminated soils.Furthermore, the economic status and the level ofeducation tend to influence the adoption of riskyhealth practices. For instance, washing hands with asoap after using a pit latrine had an equal probability17

of occurring in both the low and medium economiccadres of the respondents (ORs = 1, 2 = 0, and 95%CI = 0). It therefore follows that having or not havingmoney seems not to influence the behavior of using asoap to wash hands after latrine. However, use of asoap to wash the hands after using a latrine was lesslikely to occur among those with low education level(OR = 0.47, 2 = 3.25, 95% CI of 0.62 to 1.56)(Table 5). Utilizing a toilet paper seems to beenhanced by economic status and education level(OR = 0.38, 2 = 8.16, 95% CI of -5.22 to 5.98)(Table 4). Low educational status has earlier beenassociated with spread of infectious agents [3] andalso with spread of giardiasis in Hamadan province,Iran [18]The stool tests indicated that the most commonintestinal parasites treated at Njoro PCEA healthcenter were amoebiasis (21%), giardiasis (20%), andintestinal worms (5%), while at Njoro CountyCouncil Health Center, the intestinal parasiticinfections were amoebiasis (1%), giardiasis (0%),and intestinal worms (1%) as indicated in Tables 6 &7. This observation agrees with that made by Kean etal. [19] in which the prevalence of E histolytica tendto be significantly higher than that of G. lambliaamong homosexuals in New York City. Taherkhaniet al. [18], established that the overall prevalencerate of G. lamblia was 20% in Hamadan province,Iran. The prevalence rate of giardiasis at Hamadanwas identical to that of giardiasis at Njoro PCEAhealth center as indicated in the current research.This is a further confirmation that probably adoptionof unhygienic practices among people living in thestudy area and seeking treatment at Njoro PCEAhealth center, could be contributing to increasedchances of getting infected with E. histolytica or G.lamblia bearing in mind that both are transmittedthrough consumption of water contaminated withcysts.It is worth noting that the amoebiasis and giardiasiscases at Njoro PCEA health center were much higherthan those at Njoro County Council health center.This was probably because the high number ofchildren seeking treatment at Njoro County Councilhealth center, were rarely referred for stool tests inthe laboratory. Also being a cheaper governmenthealth center, the low economically endowedpatients tend to prefer Njoro County Council healthcenter since most of them may not have enoughmoney to pay for the laboratory tests in otherhospitals. According to Uzochukwu and Onwujekwe[20], the poor and underprivileged people in thetropics are at great risk of contracting tropicaldiseases because of their precarious living conditionsand inadequate health services. The economic statusof an individual has an influence on which treatmentsource, one will seek, when symptoms occur [21].The laboratory records for stool tests at Njoro PCEAhealth center indicated that increases in amoebiasiscorresponded to decreases in giardiasis and viseversa (Figures 1 & 2). Studies carried in animals,have shown that Giardia cysts are shed intermittently[22] and in addition, Tomkins [23] observes thatusually, a negative stool test of giardiasis does notexclude the existence of Giardia infection since theparasites may be passed only intermittently. Probablythis intermittent shedding of cysts explains theupsurge of giardiasis cases in the health center atcertain times of the year. Further research is requiredto establish whether the intermittent shedding ofcysts occurs in humans and also whether such aphenomenon applies for amoebiasis too.Alternatively, could it be due to unreliable diagnosisthat leads to the stool examination for giardia cystsbeing often negative? Misdiagnoses for giardiasishave been common and the actual prevalence may beunderestimated [24]. It has also been reported thatdiagnosis of giardia infections using fecal smear isconsidered difficult because the cysts are small andsimilar in appearance to many pseudoparasites suchas yeasts [25]. According to Kapoor [26], manypatients who are treated for amoebiasis are actuallysuffering from giardiasis. Probably this would alsoexplain why the positive G. lamblia cases wererelatively lower than those of E. histolytica in boththe health centers. Kapoor recommends serologicaltests for Giardia serum antibodies (IgM) as a morereliable procedure for confirmation.Concurrent infections of amoebiasis and giardiasiswere totally absent from the records retrieved in thetwo health centers. This was in line with severalstudies that have recorded a lower prevalence ofamoebiasis/giardiasis concurrent infections. In astudy that involved screening of 89 high risk stoolspecimens from sexually active homosexual men,20% were infected with amoebiasis, 12% with18

giardiasis and 7% with concurrent amoebiasis andgiardiasis infections [27]. Similarly, a study carriedout in Nigeria showed a lower amoebiasis/giardiasisconcurrent infection (15.2%) as compared to theprevalence of amoebiasis alone (27.6%) in childreninfected with Plasmodium falciparum [12].ConclusionThese findings suggest that amoebiasis and giardiasisare relatively common phenomena whenever a stooltest is carried out especially at Njoro PCEA healthcenter. There is need for further investigation on thesources and quality of water for the residents in thestudy area. Previous studies in Njoro watershedshave raised health concerns [28]. Control of waterborne diseases requires adoption of hygienicpractices and appropriate lifestyles which can bemade popular through health education programs inthe study area.AcknowledgementsWe the authors would like to thank DaystarUniversity, the Department of Research, Publicationand Consultancy for funding this research. We aregrateful to James Njuguna and Samuel Mwaura fortheir active role in the collection of data and also theMedical Officers in Nakuru and Molo Districts forallowing us to obtain data from the health centersunder their jurisdiction. We appreciate all therespondents in the study area and the staff at NjoroPCEA and Njoro County Council Health Centers fortheir cooperation.References1. World Health Organization. Constitution ofthe World Health Organization – Basic Documents,Forty-fifth edition, Supplement, October, 2006; p 1.2. WHO. Information support for new PublicHealth Action at District level. A report of a WHOexpert committee. WHO technical report series,Geneva, Switzerland. 1994b; p 1-4.3. Ross, J.T., Blair, H.S., Edwin, R. and Van T.Health and illness in the community OxfordUniversity Press Inc. New York, USA. 2003; p 3-76.4. Taylor, D. J., Green, N.P.O.and Soper, R.Biological Science. (3 rd ed.). Cambridge UniversityPress.1998; p 495-531.5. Petit, P. L. C. Analysis of infectious diseasesin rural tropical areas. African Journal of HealthSciences.1994; 1 (3): p 108-115.6. Wani, S. A., Ahmad, F., Zargar, S. A.,Ahmad, Z., Ahmad, P. & Tak, H. Prevalence ofintestinal parasites and associated risk factors amongschool children in Srinagar City, Kashmir, India.Journal of Parasitology. 2007; 93 (6): p 1541 –1543.7. Brooks, G. F., Carroll, K.C., Butel, J.S. andMorse, S. A. Medical Microbiology. (24 th ed.).McGraw-Hill Companies. 2007; p 659-672.8. Talaro, K. P. Foundations in Microbiology.(7 th ed.). McGraw-Hill Companies Inc. 2009; p 689-694.9. Forbes, B. A., Sahm, D. F. and Weissfeld,A. S. Bailey & Scotts Diagonostic Microbiology.(12 th ed.). Mosby Elsevier. 2007; p 543-615.10. Fishback, F. T. & Dunning, M. B. A Manualof Laboratory and Diagonostic Tests. (8 th ed).Wolters Kluwer/ Lippincott Williams& Wilkins.2009; p 285-309.11. Wanke, C., Butler, T. & Islam, M.Epidemiologic and clinical features of invasiveamebiasis in Bangladesh: A case control comparisonwith other diarrheal diseases and post-mortemfindings. American Journal of Tropical Medicineand Hygiene. 1988; 38 (2): p 335-341.12. Nwanguma, B. & Alumanah, E. Concurrentgiardiasis and amoebiasis infections in Nigerianchildren diagnosed with Plasmodium falciparummalaria: prevalence and pathophysiologicalimplications. The Internet Journal of TropicalMedicine. 2009; 6 (1).13. Kinuthia, G.K., Kiarie-Makara, M.W.,Gicheru, M.M., Kabiru, E.W and Lee, Don-Kyu.Relationship between control of parasitic infectionsand poverty levels: a case study of Njoro District,Kenya. Kosin Journal of Health Sciences. 2010; 20:p 77-95.14. Stanhope, M. and Lancaster, J. PublicHealth Nursing. (7 th ed.). Mosby Inc. 2008; p 734 –751.15. Clemen-Stone, S., McGuire, S. L. & Eigsti,D. G. Comprehensive Community Health Nursing.(6 th ed.). Mosby Inc. 2002; p 406 – 409.16. Meena, S. Impact of Health Educationprogramme on the knowledge and practices of schoolchildren regarding personal hygiene in rural Panipat.International Journal of Educational Sciences. 2009;1(2): p 115 – 118.17. Radford, A. Parasites and diarrhea. Theinternational newsletter on the control of diarrhoeal19

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